Electronic health records and electronic medical billing in today's mental health practice.

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counselingVOL . 17 NO. 3

30 christian counseling today VOL. 17 NO. 3

christian counseling today VOL. 17 NO. 3 31

ANTHONY CENTORE & RYAN NE ACE

Electronic Health Records (EHR) and Electronic Medical BillingIN TODAY’S MENTAL HEALTH

COUNSELING PRACTICE

The pressure to practice online and

document and bill in a paperless

system seems to be coming from all

directions with increasing fervor, but

many counselors are finding the transition difficult and,

perhaps, confusing. For some of us, the major road

block to a paperless practice is the steep technological

learning curve or not having a sufficient grasp of the

potential legal, ethical, and liability issues. Additionally,

from our experience, an equally large cost of making

the transition is, well, the actual monetary cost.

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$44,000 in Incentives! (just not for you)On February 17, 2009, President Obama signed into law a $789 billion dollar economic stimulus package, which included the Health Information Technology for Economic and Clinical Health Act (HITECH). Under HITECH, qualified providers can receive up to $44,000 in Medicare bonus incentives if they demonstrate the “meaningful use” of an Electronic Health Record (EHR) system.

Does $44,000 sound good? Curb your enthusiasm. Unless you are an M.D. who is billing Medicare, you won’t be seeing a penny. The stimulus

package doesn’t account for mental health professionals trying to turn the electronic corner.

EHR and Mental Health ProfessionalsToday, incentivized by HITECH, medical software sales are booming. In March of this year, Fast Company magazine named the EHR and billing company, Athenahealth, one of the world’s 50 most innovative compa-nies; as they cover more than 23,000 providers and show revenue growth greater than 35%. We contacted Athenahealth to get estimated rates for a counseling practice of six clinicians.

First, they explained that they don’t have EHR for behavioral health, only practice management and billing solu-tions. Then, they explained that they don’t provide full outsourced billing. Instead, they offer what they call “co-sourcing,” meaning that some of the work is outsourced to Athenahealth, but a practice administrator is still needed to do a good amount of the legwork on an in-house basis. For this, setup costs are $17,000, plus travel expenses for Athenahealth’s onsite trainers. In addition, they charge 7.12% (which includes a percentage of the co-pay) on reimbursed claims of $75 (an average behavioral health claim), and a higher


percentage if the claims are less than $75. Part of the problem, a representa-tive of Athenahealth explained, is that since behavioral health practices receive so little per claim, a high percentage fee is needed to offset the cost of the work that could be involved in chasing down monies from insurance companies.

Here are some quotes from other EHR and Billing Software/Service Providers: Procentive: A “minimum” setup

cost of $5,500.00, and $500.00 per month thereafter. They offer tech-nical support for only one member of your staff, who acts as a “cham-pion” (their term) to teach the rest of your clinical practice to use the software.

Athena Software (unaffiliated with Athenahealth): For 10 user licenses, they offer two options. Option 1: purchase the software and host it on your own server for $13,800. Option 2: have Athena host the software for your staff to access remotely. This costs $9,390.00 for the first year, and $8,400.00 each year thereafter.

AdvancedMD: Rates are so high on a per-user basis (nearly $1,000.00 per month), that even if a behav-ioral health practice made infinity dollars, it wouldn’t be affordable because no M.A. or Ph.D. behav-ioral health provider bills enough to justify the per-user cost.

Practice Fusion: The EHR solu-tion is free! However, they don’t offer billing or practice management software. They recommend using the billing software, Kareo, which they are working to integrate with their own software (integration isn’t available yet). Kareo costs $199.00 per user, per month.

Office Ally: see below

One Counseling Practice’s Journey into the PaperlessAt Thrive Boston Counseling in Cambridge, Massachusetts, it is in our

“DNA” to continually try new processes that could improve the care we provide our clients. We thought that an EHR system would help us to better organize records and make them easier to retrieve when requested by clients. As director, I (Anthony) also saw value in having a solution that combines note-taking with third-party billing.

In choosing an EHR platform, our team of therapists sorted through what features would be most helpful for the practice. We wanted to find a Web-based program that didn’t need installation on every office computer. This eliminated many options (including the popular, but overrated, Therapist Helper and Therascribe). High costs eliminated many more. Trying demo-versions of various soft-ware suites eliminated almost everyone else, as many look like a flashback to Windows 95. We investigated prod-ucts by Siemens, Practice Fusion, ClinicSource, Emdeon, AdvancedMD, and more. In the end, we found an extremely affordable program with good customer service called “Office Ally”

(cost: $29.95 for EHR access, plus $15 per provider, per month). Even better, use of the billing software is free for third-party payers. If you’re billing the government programs (i.e., Medicare/Medicaid) for more than 50% of total claims, they charge a modest $19.95 more per month.

We began using Office Ally on September 1, 2009, and the Thrive team was initially on board and excited about the program. However, once implementation began, some started to drag their feet. Therapists wanted to focus more on client care, not learning a new software application. As it turns out, Office Ally was not nearly as user friendly as we had hoped, and the learning curve for staff was brutal. There was a lot of dialogue during the training process that sounded like this: “You need to click here, then here, then click the drop down menu here, and ignore those sections because those features don’t apply to you.”

Today, several months into our Office Ally subscription, some staff like the program and have more or less


mastered it. Others still dislike it. Our in-house insurance biller complains about it and forewarns that the software will become increasingly unable to meet our needs as the practice grows. Also, it only works well on Internet Explorer, and it has periodic bugs, crashes, and downtime.

Office Ally support has been helpful. They’re available to talk by phone during normal business hours and will walk customers through the program. However, our counselors don’t call them anymore. After the recom-mended initial two hours of phone training, our counselors tend to be overwhelmed by somewhat irrelevant information, and yet still lack mastery of the basics. Now our office manager gives 25 minutes of in-house training and repeat sessions as needed.

We considered changing our EHR and billing software regularly. However, while there might be a better solution on the market somewhere, it may take us another year to feel ready to try out a new system, as we’re still nursing our wounds from the first transition (as I write this, my insurance biller can’t process claims because some features of the software are down today). I cross my fingers that Office Ally has the software update of my dreams coming out soon.

Overall, EHR, electronic billing, and practice management software has helped. It seems our note-taking has improved, as has the organization of client files. In addition, it’s easier to view a history of sessions at a glance, and I can readily see how much each clinician has billed and how much money has been paid from insurance and co-pays. It’s also nice not to have a growing mountain of filing cabinets in the office.

Brass Tacks: EHR, HIPAA, and Client PrivacyClient data privacy is a hot topic when talking about EHR solutions. A decade ago, people were terrified regarding online security and paranoid that electronic data would jeopardize their


private information. They were right to be concerned. To be fair, privacy was a concern for paper health records as well, but the sheer volume of infor-mation that can be lost in an instant with paperless systems is staggering. Unfortunately, this isn’t just in theory.

Over the last several years, govern-ment agencies have lost personal information of U.S. citizens, including the Office of Inspector General at the U.S. Department of Transportation, which in 2006 lost a laptop containing data on 133,000 Florida residents. In March of 2008, 2,500 patients’ protected health information (PHI) was lost by the National Institutes of Health (NIH). Not to be outdone, Hannaford and Sweetbay supermarkets lost 4.2 million customer credit card numbers to hackers—oops! Sadly, there are many more stories like this; and some estimate that one in five people in the U.S. has been a victim of identity theft.

Today, a clinician can be vigi-lant 99% of the time, but one small error (e.g., connecting to the wrong wireless network, losing a USB flash drive, failing to log out of a program, or even forgetting to “blind carbon copy” (bcc) an e-mail can mean the PHI of hundreds of patients/clients, or hundreds of thousands, is compromised. Furthermore, with partnerships between various health information organiza-tions (HIO) (e.g., Orion Health, or regional HIO’s like the Wisconsin Health Information Organization, etc.), you can be tethered to the mistakes of others as well.

Keeping that in mind, here are a few of the most frequently asked Health Insurance Portability and Accountability Act (HIPAA) and Client Privacy questions as they relate to EHR (paraphrased from the U.S. Department of Health and Human Services):

Q: What is my liability for sharing

data inappropriately through an

electronic health information (EHI)

exchange network?

A: Essentially, you are only respon-sible for yourself (you, your practice, and your employees)! You are not liable for a violation of HIPAA by an HIO with which you are associated, provided an appropriate business agreement is in place, and neither you nor your HIO business associate(s) can be held liable for civil money penalties arising from HIPAA violations by the other. You’re not required to “police” your partnered HIOs. Rather, the HIO will be contractually obligated to demon-strate adequate safeguarding measures regarding PHI and report indications of noncompliance to you. However, you will be held accountable for taking appropriate action to help remedy known noncompliance by the HIO, and if you can’t rectify it, to terminate the HIO relationship.

Q: How do HIPAA authorizations

apply to EHI exchanges?

A: HIPAA requires clients’ written authorization for any use or disclo-sure of PHI not otherwise expressly permitted or required by HIPAA, the same as it would for non-electronic PHI exchanges. For example, electronic PHI disclosures for treatment, payment, or health care operations’ purposes generally don’t require HIPAA authori-zations. So, if the purpose of your EHI exchange is to share clinical information among health care providers for treat-ment, you’re fine. However, if the reason for sharing PHI is for a purpose not otherwise permitted by HIPAA, then authorization would be required (i.e., a valid and signed client consent authori-zation). The good news is that HIPAA allows authorizations to be obtained electronically (if permitted by other applicable laws).

Q: May I provide clients with their

HIPAA Notice of Privacy Practices

(NPP) electronically?

A: Yes, provided that clients agree to receive the NPP electronically. For electronic services such as eCounseling

methods like videoconferencing, e-mail, etc., the provider must send an elec-tronic NPP automatically in response to the individual’s request for service. At eCounseling.com, we recom-mend this as part of the eCounselor’s informed consent disclosures. Also, it is worthwhile to note that, except in an emergency treatment situation (e.g., suicide risk), you should also make a good faith effort to obtain a written acknowledgment of receipt, electronically or through other means. In addition, HIPAA requires electronic service providers to post NPPs on company Web sites.

Final ThoughtsSo, there is a lot to know and learn. The time, costs, rules, and knowledge base required for the paperless office makes running one a daunting, but (we think) worthwhile, task. We encourage you to take a deep breath and dive in. Ask for help and, by all means, use the Web to find sources of free advice. The paperless trend doesn’t seem to show any signs of relenting and is a growing reality in our increasingly technological world. We doubt very much that you’ll be hearing of Presidential initiatives mandating a return to hard copies anytime soon.

This is, indeed, a “whale” of a project. But remember how you eat a whale… one byte at a time.

ANTHONY CENTORE,

PH.D., is the Executive

Director of eCounseling.com.

He is also a therapist

at Thrive Boston

Counseling in Cambridge,

Massachusetts.

RYAN THOMAS

NEACE, M.A., is the

Director of Operations for

eCounseling.com. He is also

a therapist at New Start

Counseling in Lynchburg,

Virginia.

Electronic health records and electronic medical billing in today's mental health practice.

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